This chapter provides an overview of community-based interventions aimed at helping people live well with chronic illness. It starts with a discussion of the effects of preventive interventions, including healthy lifestyles, screening, and vaccination of persons living with chronic illness. The chapter then discusses other interventions, including self-management, disease management, treatment adherence management, complementary and alternative medicine, cognitive training, and efforts to increase access for and mobility among those with chronic illness. Finally, it makes the case for monitoring and evaluating implementation of these interventions and their effects and commenting on the need for dissemination and dissemination research.

Evidence-based preventive interventions recommended for the general population are relevant to living well with chronic illness. In some cases, such interventions can affect the disease process, progression, or complications of chronic disease. For example, the Look AHEAD trial for people with diabetes has shown than an intensive 1-year intervention focusing on diet, exercise, and weight loss improved weight, diabetes control, and cardiovascular risk factors, with effects persisting 4 years after the intervention (Look AHEAD Research Group and Wing, 2010; Look AHEAD Research Group et al., 2007). Even when a particular health behavior is

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4
Community-Based Intervention
INTRODUCTION
This chapter provides an overview of community-based interventions
aimed at helping people live well with chronic illness. It starts with a
discussion of the effects of preventive interventions, including healthy life-
styles, screening, and vaccination of persons living with chronic illness.
The chapter then discusses other interventions, including self-management,
disease management, treatment adherence management, complementary
and alternative medicine, cognitive training, and efforts to increase access
for and mobility among those with chronic illness. Finally, it makes the
case for monitoring and evaluating implementation of these interventions
and their effects and commenting on the need for dissemination and dis-
semination research.
PREVENTIVE INTERVENTIONS
Evidence-based preventive interventions recommended for the general
population are relevant to living well with chronic illness. In some cases,
such interventions can affect the disease process, progression, or complica-
tions of chronic disease. For example, the Look AHEAD trial for people
with diabetes has shown than an intensive 1-year intervention focusing
on diet, exercise, and weight loss improved weight, diabetes control, and
cardiovascular risk factors, with effects persisting 4 years after the inter-
vention (Look AHEAD Research Group and Wing, 2010; Look AHEAD
Research Group et al., 2007). Even when a particular health behavior is
151

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152 LIVING WELL WITH CHRONIC ILLNESS
not directly related to a person’s chronic illness (e.g., smoking and arthri-
tis), adoption of healthy lifestyles by individuals with chronic illnesses can
serve to “strengthen the host,” optimize overall health, and make them less
vulnerable to further health threats and disability. Lifestyle behavior change
cannot generally substitute for effective medical management of chronic
illness, where it is available, but often supports “living well”—improving
quality of life, ameliorating symptoms, and optimizing functional status.
Below we summarize evidence related to benefits of preventive interven-
tions for those with chronic illness as well as evidence-based strategies for
optimizing adoption of the preventive intervention. For this overview we
have relied primarily on systematic reviews and meta-analyses from such
groups as the U.S. Preventive Services Task Force (USPSTF), Cochrane
Database System Reviews, the Guide to Community Preventive Services of
the Centers for Disease Control and Prevention (CDC), and the Advisory
Committee on Immunization Practice (ACIP). In some cases, the research
summarized in these reviews has emphasized the benefits of prevention for
a particular chronic disease, but in general the body of research on living
well with chronic disease is limited.
Lifestyle Behaviors
Physical Activity
Increasing physical activity has a number of benefits for those with
chronic illnesses, including decreasing the risk of cardiovascular disease,
some cancers, and diabetes, as well as improving physical functioning
(Physical Activity Guidelines Advisory Committee, 2008). Physical activity
interventions have been shown to benefit those with chronic illnesses as well
as the general population. Whereas exercise can be expected to improve fit-
ness in most individuals, for people with chronic illnesses, what is critical
is determining the effects on quality of life, function, and progression of
their illness. For example, a systematic review of physical activity trials in
cancer survivors reports improvements related to fatigue, functional aspects
of quality of life, anxiety, and self-esteem involving exercise (Speck et al.,
2010). For type 2 diabetes patients, structured exercise programs, physical
activity, and dietary advice from a physician potentially affect the disease
course, reducing HbA1c levels (Umpierre et al., 2011). The American Col-
lege of Sports Medicine and the American Diabetes Association have issued
a joint position statement supporting participation in regular physical ac-
tivity for individuals with type 2 diabetes (Colberg et al., 2010). Increas-
ing physical activity through exercise also helps those with depression. A
Cochrane review of 23 randomized controlled trials (RCT) showed that
participants in exercise interventions showed greater reductions in depres-

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COMMUNITY-BASED INTERVENTION
sion both following treatment and at longer-term follow-up compared with
a no-treatment control group (Mead et al., 2009), although, some method-
ological weaknesses were noted in the trials (e.g., inadequate blinding of
outcome assessment). Evidence also exists that exercise may help relieve de-
pressive symptoms of older adults who have osteoarthritis (OA) (Yohannes
and Caton, 2010). The Arthritis Foundation and CDC, in their National
Public Health Agenda for Osteoarthritis (2010), recommended promotion
of low-impact aerobic and strength-building exercise for adults with OA
in the hip and/or knee. OA research indicates that land-based exercise de-
creases pain, fatigue, and stiffness and improves performance on functional
assessments (Callahan et al., 2008; Hughes et al., 2006). A Cochrane review
of exercise for knee OA concluded that both land-based and aquatic exer-
cise has short-term benefit in terms of reduced pain and improved physical
functioning (Bartels et al., 2007; Fransen and McConnell, 2008).
Physical activity appears to be helpful to people with other chronic
illnesses as well. For example, aerobic physical activity, alone or when
included in multicomponent interventions, has also been shown to be
beneficial to patients with fibromyalgia syndrome, having moderate-sized
effects on pain, fatigue, depressed mood, and quality of life (Häuser et al.,
2009, 2010). A Cochrane review on exercise for fibromyalgia indicated
that moderate aerobic exercise may benefit overall well-being and physi-
cal function, whereas strength training appears more beneficial in terms of
reducing pain, tender points, and depression (Busch et al., 2007). A limited
number of studies have been conducted to test the effects of exercise on
dementia. Results of the studies have been mixed, and the methodology
has been of low to moderate quality, but some studies have indicated that
participation in exercise is associated with such outcomes as better mobil-
ity and physical performance and improvement in activities of daily living
(ADLs) (Blankevoort et al., 2010; Littbrand et al., 2011; Potter et al., 2011;
Vreugdenhil et al., 2011); however, it is unclear whether exercise has an
effect on cognitive functioning in this population (Littbrand et al., 2011).
Although substantial evidence has accrued for the benefits of physical
activity for people with a range of chronic illnesses, there is limited evidence
to indicate what type, duration, and intensity of exercise is most helpful for
improving function, quality of life, and disease progression for most chronic
illnesses, nor are there sufficient evidence-based programs to help individu-
als with chronic illnesses to successfully adopt and maintain exercise. A
survey conducted of physical activity programs for the elderly in seven U.S.
communities highlights the problems of both insufficient demands from this
population as well as insufficient program capacity. The survey showed
that the programs were serving only approximately 6 percent of the elderly
population; however, less than 4 percent of the programs had waiting lists
for their services (Hughes et al., 2005).

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154 LIVING WELL WITH CHRONIC ILLNESS
There are few evidence-based community programs specifically for in-
dividuals with chronic illnesses that have been shown to increase physical
activity and improve outcomes, although programs developed for individu-
als with OA have been shown to be effective and successfully implemented.
For example, a randomized trial of the 8-week Arthritis Foundation’s Exer-
cise Program intervention showed effects on pain, fatigue, and self-efficacy,
with symptom improvements maintained at follow-up 6 months later. The
prevalence of a particular chronic disease may limit the usefulness of hav-
ing disease-specific physical activity programs for many chronic diseases.
However, physical activity programs that are adaptable to individual needs
may be appropriate for people with a range of chronic illnesses. An example
is EnhanceFitness, an evidence-based physical activity program developed
for older adults. EnhanceFitness is a 1-hour class that meets 3 times per
week and includes moderate intensity aerobic exercise, strength training,
flexibility, and balance-enhancing exercises. Benefits of the program include
prevention of age-related decline in health status as measured via the SF-36
health survey (Wallace et al., 1998) and improved physical performance
(Belza et al., 2006); participation in the program is also associated with
reduced health care costs for individuals making heavy use of the program
(Ackermann et al., 2008).
Several interventions are recommended by the CDC’s Guide for Com-
munity Preventive Services to increase physical activity (Community
Preventive Services Task Force, 2005a). Although these evidence-based
interventions have not necessarily been tested in populations with chronic
illnesses, several have been tested in older adults, who are more likely to
suffer from chronic illnesses. Individually tailored health behavior pro-
grams also have sufficient evidence to be recommended by the task force.
Such programs include evidence- and theory-based behavioral strategies
to modify behavior, including goal setting and self-monitoring, rewarding
positive changes in behavior, structured problem-solving skills, soliciting
social support for the behavior changes, and preventing relapse. Interven-
tions to increase social support for physical activity in community settings,
such as exercise buddy systems or walking groups, are also recommended.
Community-wide campaigns that involve sustained effort to promote high-
visibility messages about increasing physical activity have been shown to be
effective and may be combined with individual-level education/counseling
efforts. Finally, recommended policy changes and environmental interven-
tions include community-scale and street-scale urban design and land use
policies, increased access to places for physical activity combined with
informational outreach, and point of decision prompts to use stairs (Com-
munity Preventive Services Task Force, [d]). Urban design features that
enhance activity include land use policies that influence the proximity of
stores and other destinations to residential areas, aesthetics and safety, and

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connectivity/continuity of sidewalks and streets (Community Preventive
Services Task Force, [b]).
Diet
Diet and physical activity are often linked when offering interven-
tions for the prevention of chronic dieases. Although recommendations for
healthy diets come from a variety of sources, they offer similar patterns of
intake. Recommended Dietary Allowances (RDAs), Dietary Reference In-
takes (DRIs), and the Dietary Guidelines for Americans are fairly consistent
in recommending a diet that maintains a healthy weight, encouraging a rich
intake of fresh fruits and vegetables (preferably those that are dark green,
red, or orange), complex carbohydrates (whole grains), and low-fat dairy
products and minimizing saturated fats (except for mono- or polyunsatu-
rated fatty acids), lowering the consumption of salt, and taking in adequate
fluids. These recommendations are also consistent with the Healthy People
2010 and Healthy People 2020 targets.
Individuals with chronic illnesses may encounter socioeconomic is-
sues that contribute to food insecurity, a situation in which individuals
have to make choices about how to spend limited income. Fresh fruits and
vegetables may be expensive, whereas rice and potatoes are not. Food inse-
curity may also encompass challenges in procuring or preparing adequate
food. Those with disabilities may have more problems with being able to
independently shop or cook food and may rely on prepared or processed
products, which are often high in salt and fat.
It is difficult for some older people to make healthy choices if they
have not been educated in the basics of nutrition. Identifying nutritional
deficiencies is often difficult, and both poor nutrition and obesity may have
underlying etiologies that are not directly caused by poor choices about
foods consumed. Eating can become a challenge for those who have to
navigate making healthy food choices adhering to the multiple public health
messages to consume less sodium, less fat, more unsaturated fats, less trans-
fat, fewer triglycerides, more fruits and vegetables, as well as other dietary
modifications associated with managing their chronic illness.
Tobacco
Smoking cessation is an important behavior-change target for people
with chronic illnesses, particularly those whose illness is related to their
tobacco use (HHS, 1990). Data from the National Health Interview Sur-
vey indicate that many individuals with smoking-related chronic illnesses
continue to smoke; the prevalence of smoking among individuals with a
smoking-related chronic illness is 36.9 percent, 23 percent among individu-

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als with chronic illnesses that are not smoking related, and 19.3 percent
in people with no chronic illness (Rock et al., 2007). Gritz et al. (2007)
reviewed the literature with regard to benefits of smoking cessation and
effectiveness of interventions for individuals with cardiovascular disease,
chronic obstructive pulmonary disease, diabetes, asthma, cancer, and AIDS.
For these diseases, continued smoking has been shown to increase the risk
of disease exacerbation or complications. Smoking cessation interventions,
delivered primarily in health care settings or in the context of self-manage-
ment programs, have shown mixed results with regard to efficacy. More
research is needed to determine optimal smoking cessation intervention
approaches for individuals with chronic illnesses, as well as whether exist-
ing smoking cessation services are effective and accessible to individuals
with chronic illness. A state of the science conference held by the National
Institutes of Health (NIH) on smoking cessation in adults (including special
populations) concluded that self-help strategies alone were not effective at
increasing cessation rates, but combined counseling and pharmacotherapy
were largely effective (Ranney et al., 2006). However, few studies focused
on ways to reach special populations, such as those with chronic illness.
One approach, intensive smoking cessation counseling delivered to hospi-
talized patients, has not been shown to be effective.
The 2008 nicotine dependence treatment guidelines (HHS and Public
Health Service, 2008) conclude that cessation treatment, including both
counseling and pharmacological treatment, is effective for smoking cessa-
tion in patients with cardiovascular disease, lung disease, and cancer, but
that there were insufficient trials in HIV/AIDS populations. For individuals
with psychiatric illnesses, who have high smoking rates compared with the
general population, smoking cessation pharmacological (buproprion SR
and nortriptyline for depressed individuals and nicotine replacement and
buproprion SR for individuals with schizophrenia) and counseling interven-
tions have also shown effectiveness. The guidelines concluded that there is
insufficient evidence to indicate that individuals with psychiatric disorders
benefit more from interventions tailored to the psychiatric disorder or
symptoms than standard treatments. A more recent systematic review of
smoking cessation interventions for individuals with severe mental illness
confirmed that such individuals are able to quit smoking with pharma-
cological (buproprion and nicotine replacement therapy) and behavioral
interventions (individual and group therapy) that are effective in the general
population. Furthermore, those who are stable at the initiation of treatment
do not suffer increases in psychiatric symptoms (Banham and Gilbody,
2010).
Individuals with chronic illnesses can also benefit from community
efforts to encourage tobacco use cessation and reduce exposure to sec-
ondhand smoke. Tobacco policies in the community decrease exposure to

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secondhand smoke, and those in the workplace increase smoking cessation
and decrease secondhand smoke exposure. In the workplace, incentives and
competitions can be effective in increasing tobacco cessation when com-
bined with other efforts. Recommended interventions for smoking cessation
include mass media campaigns when combined with other interventions, an
increase in the unit price of tobacco products, provider reminders with and
without provider education, reduced out-of-pocket costs for tobacco cessa-
tion, and multicomponent interventions that include telephone counseling
(Community Preventive Services Task Force, [a]).
Screening and Vaccination
USPSTF has developed recommendations for clinical preventive services
based on systematic reviews of the literature. With few exceptions, recom-
mendations of USPSTF apply as well to people with chronic illnesses as they
do to people without chronic illness. The only exceptions to general preven-
tion recommendations for people with chronic illnesses involve situations
where the presence of the chronic illness changes the magnitude of benefit
or harm from the specific preventive service. For example, if the chronic
illness reduces life expectancy to a substantial degree, the potential benefit
from the preventive service (e.g., screening mammography in women with
metastatic lung cancer) may be reduced and the preventive service becomes
inappropriate. Likewise, if the chronic illness increases the testing burden or
the potential psychological or physical harm of the preventive service (e.g.,
colorectal cancer screening in people with advanced dementia), again the
preventive service is inappropriate. As with individual preventive services
for anyone, it is important for the health care system to assist people with
chronic illnesses to consider the potential benefits and harms to make an in-
formed decision about preventive services. Sometimes, people with chronic
illnesses may decide that the burden of testing and possible work-up and
treatment is not worth the potential benefit, or that the added burden of yet
another medication (even if prophylactic) is more than they are willing to
bear. Some people with chronic illnesses may decide that, given their situa-
tion, some preventive services are just not a high enough priority for them
to spend the time and energy (both physical and emotional) to engage in
them. In these situations, the health care systems should respect and support
the person’s decision (Sawaya et al., 2007).
Chronically ill individuals often suffer from multiple chronic conditions
(MCCs) (HHS, 2010), and thus relevant outcomes for preventive interven-
tions may be broader than those traditionally used to assess effectiveness of
preventive services and include multiple domains. Some of these domains
may be represented by a multiplicity of measures that create difficulties for
clear, straightforward interpretation. The strategic framework on MCCs of

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158 LIVING WELL WITH CHRONIC ILLNESS
the U.S. Department of Health and Human Services (HHS) identifies the
definition of relevant health outcomes for individuals with MCCs as one
of its priority objectives (HHS, 2010). Furthermore, the specific benefit of
a preventive intervention for individuals with chronic illnesses may not
be known. Randomized clinical trials of preventive services often exclude
individuals with chronic illnesses or recruit them in insufficient numbers
to allow subgroup analyses that could identify benefits and risks of the
intervention. The risk of harm from the intervention might be higher for
individuals with chronic illnesses. For example, in screening for cancer in
those with heart failure or chronic obstructive pulmonary disease (COPD),
consideration should be made of the risk of overtreatment and the indi-
vidual’s ability to tolerate treatment if a cancer is identified. As another
example, people who are older and with chronic illnesses suffer more
complications from screening colonoscopy than do younger people without
chronic illnesses (Warren et al., 2009).
Influenza vaccines are one clinical preventive intervention for which
there is evidence of benefit for individuals with chronic illness. The PRISMA
study was a nested case-control study that evaluated the risk reduction of
influenza vaccine among adults between the ages of 18 and 64 with chronic
illness (Hak et al., 2005). In this age group, influenza vaccination prevented
78 percent of deaths, 87 percent of hospitalizations, and 26 percent of visits
to a general practitioner. Influenza vaccine is recommended for all individu-
als age 6 months and older, but special emphasis is placed on immunizing
individuals at higher risk of complications, including those with chronic
illnesses, such as pulmonary and cardiovascular disease (except hyperten-
sion); renal, hepatic, and hematological diseases; neurological disorders;
and metabolic disorders, such as diabetes. Individuals who are immuno-
compromised, because of either an illness or a treatment, are also a high
priority for influenza vaccine outreach (CDC, 2011).
Because these clinical preventive services are for the most part delivered
through health care settings, and individuals with chronic illnesses may
have more contact with the health care system, they may have increased
opportunities to receive preventive care. A study of preventive health care
in individuals with lupus found that they had comparable levels of cancer
screening to a general population sample and a sample of patients with
other chronic illnesses (diabetes, asthma, and heart disease). The sample
with lupus had higher rates of influenza vaccination and lower rates of
pneumococcal vaccination than the general population had, and the pa-
tients with other chronic illnesses had lower rates of both types of vac-
cination (Yazdany et al., 2010). Having a primary care provider and a
rheumatologist involved in care increased the likelihood that individuals
with lupus received the influenza vaccine. Baldwin and colleagues (2011)
studied preventive care in colorectal cancer survivors from the year prior

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COMMUNITY-BASED INTERVENTION
to diagnosis to up to 8 years postdiagnosis using SEER (Surveillance,
Epidemiology, and End Results)–Medicare data. Patients with stage 0 or 1
colorectal cancer had higher rates of mammography screening and having
the influenza vaccine than did those with stage 2 or 3 cancer and controls.
For individuals with stage 2 or 3 cancer, their use of mammography and in-
fluenza vaccine increased from prediagnosis through posttreatment and sur-
vivorship phases, indicating that perhaps either the “teachable moment” of
the cancer diagnosis or their increased contact with the health care system
facilitated their receipt of preventive services (Baldwin et al., 2011).
The Guide to Community Preventive Services recommends a number of
measures to increase uptake of screening in the general population, which
would be likely to impact those with chronic illnesses as well. Education
efforts using one-to-one methods (breast and cervical cancer screening) or
small-group education (breast cancer screening only) as well as small media
(videos and print material to encourage people to obtain screening) have
shown to increase screening uptake. Client reminder systems (breast and
cervical cancer screening), a reduction in structural barriers (breast cancer
screening only), and a reduction in out-of-pocket costs (breast cancer screen-
ing only) also increase screening rates (Community Preventive Services Task
Force, [a]). Offering the influenza vaccination in the workplace to both
health care and non–health care workers is recommended for increasing in-
fluenza vaccination rates and would be a useful adjunct to offering vaccina-
tions in health care settings (Community Preventive Services Task Force, [c]).
Barriers to Lifestyle Behavior Change for Individuals with Chronic Illness
Efforts to increase adoption of healthy lifestyle behaviors among in-
dividuals affected by chronic illness should be undertaken with sensitivity
to the additional barriers often faced by these populations. Individuals
with low socioeconomic status, and African Americans and Hispanics, are
more likely to experience chronic illnesses and impaired functional status
(Kington and Smith, 1997), and therefore they may live in neighborhoods
that have a high density of advertising of tobacco and alcohol products
and outlets where such products may be purchased (Barbeau et al., 2005;
Gentry et al., 2011), as well as poor access to fitness and recreation facili-
ties, or supermarkets that sell fresh fruits and vegetables (Estabrooks et al.,
2003; Larson et al., 2009). Furthermore, fitness and recreation facilities, as
well as outdoor areas supporting physical activity, may not be accessible
or welcoming to individuals with disabilities (Rimmer et al., 2004, 2005).
Additionally, neighborhood safety is generally poorer in low socioeconomic
status (SES) neighborhoods (Wilson et al., 2004) and may disproportion-
ately affect people with chronic illnesses, particularly those with functional
limitations who are more vulnerable to violence (Levin, 2011), falls, and

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physical barriers. Fear of violence in the community may suppress physi-
cal activity and also affects healthy eating patterns. Disparities such as
these point to the need for environmental and policy approaches to sup-
porting healthy lifestyle behavior among individuals with chronic illnesses
(Brownson et al., 2006), including availability and accessibility of outlets
for physical activity and healthy eating, and addressing violence in the com-
munity (Cohen et al., 2010); such approaches may be even more important
for these populations than the general population.
Other Living Well Interventions
Self-Help Management
In 2005, 133 million people in America had at least one chronic illness
(Partnership for Solutions National Program Office, 2004). About 25 per-
cent of individuals with chronic illnesses have activity impairments (Part-
nership for Solutions National Program Office, 2004). The management
of chronic illness often requires a multifactored approach among health
care team members, informal caregivers, and the patient. One approach to
minimizing the costs and instilling individual responsibility and confidence
is the development of self-management programs. These programs offer
information and behavioral strategies that provide tools for individuals to
use in caring for their chronic illness. These programs need to be based on
what the patients perceive as problematic, not on what health care provid-
ers think the focus of education should be (Lorig and Holman, 2003).
Self-management requires a set of skills that can be taught to individu-
als with chronic illness. These include problem solving, decision making,
resource utilization, developing a patient-provider partnership, and taking
action (Lorig and Holman, 2003). The development of self-management
strategies is often done on an individual case basis. The dissemination of
an evidence-based program for the self-management of chronic disease
in the community is a recent phenomenon (Lorig et al., 2005). A 6-week
program called the Chronic Disease Self-Management Program (CDSMP)
was developed by a group of investigators at Stanford University in the
1990s. The program dissemination was implemented and evaluated at
Kaiser Permanente, an integrated health care system that serves well over 8
million people (Lorig et al., 2005). In a 2-year follow-up, the investigators
examined health status and health resource utilization (Lorig et al., 2001a).
Health resource utilization, measured as the number of emergency room
and outpatient visits, was reduced, and there was an improvement in self-
efficacy or the confidence in one’s ability to deal with health problems. In
a smaller study that measured outcomes after one year, there were similar

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results: fewer emergency room and outpatient visits, although the results
were not statistically significant (Lorig et al., 2001b).
Self-management of chronic diesases has since been evaluated in a
variety of clinical trials. There are conflicting reports of their effectiveness
and essential components (Chodosh et al., 2005). In a meta-analysis of the
literature, 780 studies were reviewed and 53 were selected for analysis,
including 26 diabetes programs, 14 osteoporosis studies, and 13 hyperten-
sion studies (Chodosh et al., 2005). The diabetes and hypertension stud-
ies reviewed showed clinical improvements in the participants’ outcome
measures (HbA1c and both systolic and diastolic blood pressure), but the
osteoarthritis participants had only minimal impact on the outcome mea-
sures for pain and function. However, the investigators reported that the
meta-analysis had limitations, in that the studies included were of variable
quality. Self-management programs have been applied to different chronic
disease interventions for osteoarthritis (Wu et al., 2011), depression (Zafar
and Mojitabai, 2011), diabetes (Ismail et al., 2004; Moore et al., 2004),
hypertension (Schroeder et al., 2004a, 2004b), and others (Chodosh et al.,
2005; Gardetto, 2011).
There are other self-management programs, most notably Matter of
Balance, a self-management program designed to decrease the risk of falls.
The efficacy of a fall prevention program seems to be linked to a perception
of need on the part of the individual (Calhoun et al., 2011). A recent meta-
analysis concluded that fall prevention programs do reduce falls by 9–12
percent as reported in the literature (Choi and Hector, 2011).
Participation rates in patient self-management programs seem variable,
depending on the program, the population, and the locale (Bruce et al.,
2007). A recent study conducted in Canada that reviewed the implementa-
tion and success of a self-management program for individuals with chronic
illnesses found a general lack of understanding about self-management, a
minimum of evidence-based practices, and a tendency to focus on a single
illness entity. The challenge was that most of the patients had multiple
comorbidities and self-management programs did not account for this and
proved to be a burden for patients and providers alike (Johnston et al.,
2011).
Disease Management
Disease management programs are widely used by health plans and
overlap with self-management programs. Disease management programs
seek to detect patients with chronic illnesses and to increase their use of
self-management and coordinated care with an eye toward improving out-
comes and controlling costs (Bernstein et al., 2010). In 2010, 67 percent
of large employers consisting of 200 or more workers included disease

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